PERSONAL DETAILS:

Name
Address
City/Town
Post Code
Telephone Number
E-mail
Date of Birth
National Insurance Number

EMPLOYMENT DETAILS:

Name of Employer (optional)
Address
City/Town
Post Code
Job Title
Start of employment date
Finish date (if applicable)
Number of Employees, please choose	no answer 0-25 26-50 51-75 76-100 101-125 126-150 151-175 176-200 200+
Salary (per annum)
Salary (monthly/weekly) gross

Other benefits, please choose
Company Car        Mileage Allowance  Mobile Phone       Pension          
Other, please Specify            

Have you resigned already?	No Yes
If yes, upon which date?
Have you been dismissed?	No Yes
when, date
on what grounds
How long have you been with employed with this employer continuously?

DETAILS OF COMPLAINT:

Date of incident	Brief description of what happened
Incident 1,
Incident 2,
Incident 3,
Incident 4,
Incident 5,

WITNESS DETAILS:

Were there any witnesses to the incident(s)?	No Yes
Are they willing to attend at Tribunal?	No Yes

GRIEVANCE PROCEDURE:

Does your company have a Grievance Procedure?	No Yes
Have you invoked the Grievance Procedure?	No Yes

If yes, please detail the procedure followed providing dates of any correspondence, Hearings together with the outcome:

DISCRIMINATION CLAIMS:

Do you think you have been discriminated against on the grounds of your race; sex; ill health?
            Race                Sex                 Ill health

Date of incident	Brief description of what happened
Incident 1,
Incident 2,
Incident 3,
Incident 4,
Incident 5,

Have you complained to your employer?	No Yes
When? Please provide the complained date(s)/approximate date(s)